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Atrial Fibrillation - From Diagnosis to Treatment - St Vincent's Birmingham

CME Lecture for the medical staff at St Vincent's Hospital.

Atrial fibrillation is a common rhythm disorder. There are many treatment options available today.

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Atrial Fibrillation - From Diagnosis to Treatment - St Vincent's Birmingham

  1. 1. Jose Osorio, MD www.theafcenter.com
  2. 2. www.theafcenter.com
  3. 3. Atrial Fibrillation Demographics by Age U.S. population x 1000 Population with AF x 1000 Population with atrial fibrillation 30,000 500 400 U.S. population 20,000 300 200 10,000 100 0 0 <5 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- 90- >95 9 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 89 94 Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473. Age, yr www.theafcenter.com
  4. 4. 5 4.78 5.16 5.42 5.61 4.34 4 3.80 3 2 2.08 2.26 2.44 2.66 2.94 3.33 1 20 60 20 50 20 45 20 40 20 35 20 30 20 25 20 20 20 15 20 10 20 05 20 00 0 19 95 Adults with AF, MM 6 Year Go A, et al. JAMA. 2001;285:2370-2375. www.theafcenter.com
  5. 5. Atrial Fibrillation Costs to the health care system A LOT!! Average hospital stay = 5 days Mean cost of hospitalization = $18,800 Does not include: Costs of cardioversions/ablations/surgery Costs of drugs/side effects/monitoring Costs of AF-induced strokes Estimated US cost burden 15.7 billion www.theafcenter.com
  6. 6. First Detected Paroxysmal (Self-terminating) Persistent (Not self-terminating) Permanent www.theafcenter.com
  7. 7.  Paroxysmal ◦ few seconds to days, then stops on its own ◦ Typically younger, healthier patients  Healthier “Lone Afib” Persistent ◦ does not stop by itself but will stop with a medication or cardioversion  Permanent ◦ present all the time and cannot be fixed with medication or cardioversion More Comorbidities
  8. 8. • Identify potential causes and comorbidities • Stroke Prevention • Treating AF symptoms www.theafcenter.com
  9. 9.    Thyroid Disease. Alcohol Consumption. Cardiac Surgery.       15% to 33% of CABG patients 38% to 64% of valve surgery. Valvular Disease. Heart Failure. WPW Hypertension/LVH www.theafcenter.com
  10. 10. www.theafcenter.com
  11. 11. Atrial Fibrillation Obstructive Sleep Apnea 20 – 15 – OSA Cumulative 10 – Frequency of AF (%) 5– No OSA 0– 0 1 2 3 4 5 6 No OSA 8 9 10 11 12 13 14 15 Years Number at Risk OSA 7 844 709 569 478 397 333 273 214 173 134 110 94 70 46 29 8 2,209 1,902 1,616 1,317 1,037 848 641 502 393 296 217 195 130 94 69 28 Cumulative frequency curves for incident atrial fibrillation (AF) for subjects < 65 years of age with and without obstructive sleep apnea (OSA) during an average 4.7 years of follow-up. p = 0.002 Gami, et al. JACC 2007;49:565-71 www.theafcenter.com
  12. 12. • Identify potential causes and comorbidities • Stroke Prevention • Treating AF symptoms www.theafcenter.com
  13. 13. Atrial Fibrillation and Strokes • 5-fold higher risk of stroke • Over 87% of strokes are thromboembolic • >90% of thrombus originates in the Left Atrial Appendage (LAA) • Stroke is the number one cause of long-term disability and the third leading cause of death in patients with AF www.theafcenter.com
  14. 14. • 500,000 strokes/year in U.S. • Up to 20% of ischemic strokes occur in patients with atrial fibrillation Percent of Total Strokes Attributable to Atrial Fibrillation 35 30 25 20 % 15 10 5 0 50-59 60-69 Stroke 22(18), 1991 70-79 80-89 3000838-7 www.theafcenter.com
  15. 15.  >90% of strokes in AF patients are secondary to LAA emboli www.theafcenter.com
  16. 16. www.theafcenter.com
  17. 17. www.theafcenter.com
  18. 18. www.theafcenter.com
  19. 19. www.theafcenter.com
  20. 20. Cardiac failure Hypertension Age >75 Diabetes Stroke – 2 points Limitation CHADS2 of 0 or 1 patients may still have a moderate risk for stroke www.theafcenter.com
  21. 21. www.theafcenter.com
  22. 22. www.theafcenter.com
  23. 23. Atrial Fibrillation Stroke Prophylaxis www.theafcenter.com
  24. 24. Atrial Fibrillation Challenges in Stroke Prevention • Warfarin • Not always well-tolerated • Less than 50% of patients eligible are being • Time at therapeutic range - low • Prevent Ischemic Strokes  Cause Hemorrhagic Strokes www.theafcenter.com
  25. 25. • Warfarin still cornerstone of therapy • Assuming 51 ischemic strokes/1000 pt-yr • Warfarin prevented 28 strokes at expense of 11 fatal bleeds • Aspirin prevented 16 strokes at expense of 6 fatal bleeds • Warfarin • 60-70% risk reduction vs no treatment • 30-40% risk reduction vs aspirin Cooper: Arch Int Med 166, 2006 Lip: Thromb Res 118, 2006 3000838-10 www.theafcenter.com
  26. 26. Low INR <1.6 Efficacy 4-fold Therapeutic INR 2-3 High INR >3.2 0 20 40 60 80 100 % Bungard: Pharmacotherapy 20:1060, 2001 3000838-14 www.theafcenter.com
  27. 27.  Novel Anticoagulants ◦ Pradaxa – Dabigatran ◦ Xarelto – Rivaroxaban ◦ Eliquis – Apixaban www.theafcenter.com
  28. 28.  Contraindications for anticoagulants: ◦ ◦ ◦ ◦ ◦ Bleeding Hemorrhagic Stroke Frequent Falls Low Platelet Count Recent Surgery Patient’s choice www.theafcenter.com
  29. 29.   What can we offer patients that cannot take oral anticoagulants? Or do not want to take OACs ◦ Left Atrial Appendage Closure www.theafcenter.com
  30. 30. www.theafcenter.com
  31. 31. Pericardial Access www.theafcenter.com
  32. 32. www.theafcenter.com
  33. 33. www.theafcenter.com
  34. 34. www.theafcenter.com
  35. 35. www.theafcenter.com
  36. 36. www.theafcenter.com
  37. 37. www.theafcenter.com
  38. 38. 3000838-18 www.theafcenter.com
  39. 39. Device Day 0 Day 2-14 Preimplant interval Day 45 postimplant Device subject takes warfarin Ongoing to 5 years Device subject has ceased warfarin Control Device subject gets implant Randomize Control subject takes warfarin Day 0 Ongoing to 5 years 3000838-60 www.theafcenter.com
  40. 40. • Primary Efficacy Endpoint • All stroke: ischemic or hemorrhagic • deficit with symptoms persisting more than 24 hours • • or • symptoms less than 24 hours confirmed by CT or MRI Cardiovascular and unexplained death: includes sudden death, MI, CVA, cardiac arrhythmia and heart failure Systemic embolization www.theafcenter.com
  41. 41. Baseline Risk Factors WATCHMAN N= 463 Control N= 244 P-value 1 158/463 (34.1) 66/244 (27.0) 0.3662 2 157/463 (33.9) 88/244 (36.1) 3 88/463 (19.0) 51/244 (20.9) 4 37/463 (8.0) 24/244 (9.8) 5 19/463 (4.1) 10/244 (4.1) 6 4/463 (0.9) 5/244 (2.0) Paroxysmal 200/463 (43.2) 99/244 (40.6) Persistent 97/463 (21.0) 50/244 (20.5) Permanent 160/463 (34.6) 93/244 (38.1) 6/463 (1.3) 2/244 (0.8) 57.3 ± 9.7 56.7 ± 10.1 460 (30.0, 82.0) 239 (30.0, 86.0) CHADS2 Score AF Pattern Unknown LVEF % 0.7623 0.4246 www.theafcenter.com
  42. 42. Randomization allocation (2 device : 1 control) Device Cohort 900 pt-yr Posterior Probabilities Control Events (no.) Total pt-yr Rate (95% CI) Events (no.) Total pt-yr Rate (95% CI) Rel. Risk (95% CI) Noninferiority Superiority 20 582.3 3.4 (2.1, 5.2) 16 318.0 5.0 (2.8, 7.6) 0.68 (0.37, 1.41) 0.998 0.837 Event-free probability 1.0 ITT Cohort: Non-inferiority criteria met WATCHMAN 0.9 Control 0.8 0 365 730 1,095 52 92 12 22 Days 244 463 147 270 3001664-2 www.theafcenter.com
  43. 43.   Oral Anticoagulation is still considered first line therapy Lariat Device ◦ Reserved for patients with Contraindications to oral anticoagulants  Watchman device ◦ Great results in patients that were eligible to take warfarin ◦ May become first line therapy www.theafcenter.com
  44. 44.  What if my patient is back to Sinus Rhythm?  Does he still need anticoagulation?  What about after cardioversion? www.theafcenter.com
  45. 45. 30 Rate Rhythm 25 Mortality, % 20 p=0.078 unadjusted 15 p=0.068 adjusted 10 5 0 0 1 2 3 Rhythm N: 2033 1932 Time (years) 1807 1316 Rate N: 2027 1925 1825 1328 4 5 780 255 774 236 The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833. www.theafcenter.com
  46. 46. Rate Rhythm Ischemic stroke 77 (5.5%)* 80 (7.1%)* INR < 2.0 27 (35%) 17 (21%) Not taking warfarin 25 (32%) 44 (55%) * p=0.79 The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833. www.theafcenter.com
  47. 47.   AFFIRM has demonstrated that rate control is an acceptable primary therapy in a selected high-risk subgroup of AF patients with minimal symptoms Discontinuation of OAC in patients with risk factors for stroke after CV or while on rhythm control drugs is not appropriate ◦ Asymptomatic recurrences www.theafcenter.com
  48. 48. • Identify potential causes and comorbidities • Stroke Prevention • Treating AF symptoms www.theafcenter.com
  49. 49. ANTITHROMBOTIC RX AND RHYTHM CONTROL OR ? RATE CONTROL www.theafcenter.com
  50. 50. ANTITHROMBOTIC RX AND RHYTHM CONTROL Greater AF Symptoms OR ? RATE CONTROL Minimal or no symptoms www.theafcenter.com
  51. 51. Atrial Fibrillation Treatment Options • Rate Control • Rhythm Control • Medications • Cardioversion • Ablation www.theafcenter.com
  52. 52. www.theafcenter.com
  53. 53. 74 yo medically refractory AF, Echo – Normal AA Rx - Verapamil, Rythmol, Betapace, Norpace I II III V1 RSPV dist RSPV prox * LIPV RA www.theafcenter.com
  54. 54. www.theafcenter.com
  55. 55. Atrial Fibrillation Afib Triggers www.theafcenter.com
  56. 56. Atrial Fibrillation Afib Triggers www.theafcenter.com
  57. 57. www.theafcenter.com
  58. 58. Radiofrequency Ablation Cryoablation www.theafcenter.com
  59. 59. www.theafcenter.com
  60. 60. 1. Access targeted vein 2. Inflate and position 3. Occlude and ablate 4. Assess PVI 60 60 www.theafcenter.com
  61. 61. Delay Increased Delay Isolation Images: Courtesy of Dr. Schwagten, ZNA Middelheim, Belgium (above) and Dr. Vogt, Herz- und Diabeteszentrum NRW, Germany (right) www.theafcenter.com
  62. 62. Lasso Guided PV Isolation Before Ablation During Ablation A PV A PV After Ablation I PV-d CS-p CS-7/8 CS-5/6 CS-3/4 CS-d HRA PV-1/2 PV-2/3 PV-3/4 PV-4/5 PV-5/6 PV-6/7 PV-7/8 PV-8/9 PV-9/10 PV-10/1 100 ms A www.theafcenter.com
  63. 63. Pappone C, et,al.J Am Coll Cardiol. 2006 Dec 5;48(11):2340-7. www.theafcenter.com
  64. 64. Freedom from AF Recurrence P<0.001 Pappone C, J Am Coll Cardiol 2003 www.theafcenter.com
  65. 65. QOL Following Ablation vs. Medical Therapy for AF Pappone C, et.al. JACC 42:185-97, 2003 www.theafcenter.com
  66. 66. LV Function after AF Ablation Patients with of Without CHF Hsu LF, et.al., NEJM 351:2372-83, 2004 www.theafcenter.com
  67. 67. www.theafcenter.com
  68. 68. CRYO Procedure Experience Impacts Treatment Success P < 0.001 by quartile (Wald) OR = 1.14 for each procedure Treatment Success 100% 90% 69% 66% 80% 56% 60% 40% 20% 0% 25 centers n=43 1st and 2nd procedures 14 centers n=38 3rd – 5th procedures 10 centers n=42 6th – 11th procedures 4 centers n=40 12th – 23rd procedures 69 www.theafcenter.com
  69. 69.  Candidates for ablation ◦ Symptomatic atrial fibrillation despite medical therapy  Paroxysmal Afib  easy to determine  Persistent Afib  Symptoms related to Afib?  Structural Heart Disease / LA dimension  Comorbidities www.theafcenter.com
  70. 70.  AF is rarely life-threatening and is typically recurrent  Treatment goals in symptomatic pts ◦ frequency, duration and severity of recurrences ◦ Reduce Stroke Risk ◦ Minimize risk of tachycardia induced cardiomyopathy www.theafcenter.com
  71. 71. Atrial Fibrillation   Highly Prevalent Condition Treatment ◦ driven by symptoms  Atrial fibrillation ablation ◦ ◦ ◦ ◦   Effective Reduces or eliminates symptoms Reduces risk of stroke Significantly improves quality of life www.theafcenter.com 205-939-0073 www.theafcenter.com
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CME Lecture for the medical staff at St Vincent's Hospital. Atrial fibrillation is a common rhythm disorder. There are many treatment options available today.

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